Substance abuse in patients with attention-deficit hyperactivity disorder : therapeutic implications

Decision-Making Deficits in ADHD Are Not Related to Risk Seeking But to Suboptimal Decision-Making: Meta-Analytical and Novel Experimental Evidence

Objective: ADHD is related to decision-making deficits in real-life (e.g., substance abuse) and on experimental tasks (increased preference for risky options). In most tasks, risk and expected value are confounded (risky options have lowest expected value), making it impossible to disentangle risky from suboptimal (i.e., not choosing highest expected value) decision-making. We differentiated between risky and suboptimal decision-making in ADHD in two studies. Method and Results: First, on a multilevel meta-regression analysis (k = 48, n_ADHD = 1,144, n_Control = 1,108), ADHD and controls differed if the risky option was suboptimal (ADHD choosing more risky/suboptimal), whereas groups performed similar if the risky option was not suboptimal. Second, an empirical study showed that adults with ADHD (n = 40) made more suboptimal, but not more risky choices than controls (n = 40). Conclusion: These results contribute to a growing body of evidence that decision-making deficits in ADHD are driven by suboptimal decision-making and not by risk seeking.

Are non-abstinent reductions in World Health Organization drinking risk level a valid treatment target for alcohol use disorders in adolescents with ADHD?

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Changes in WHO alcohol risk level are highly variable in youth treated for ADHD/SUD.

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Achieving > 2-level reduction in WHO risk is linked to improvements in functioning.

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Achieving > 2-level reduction in WHO risk is linked to decreased ADHD symptoms.

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> 2-level reduction in WHO risk may be a valid non-abstinent AUD outcome in youth with ADHD/SUD.

Introduction

Abstinence from drinking represents the primary treatment target for alcohol use disorders (AUD) in youth, but few adolescents who engage in problematic drinking seek treatment. A reduction in World Health Organization (WHO) drinking risk level has been established as valid and reliable non-abstinent treatment target for AUD in adults but remains unstudied in youth.

Methods

The present study used data from the NIDA-CTN-0028 trial to examine associations between reductions in WHO drinking risk level and changes in global functioning and attention-deficit hyperactivity disorder (ADHD) symptoms during treatment in a sample of adolescents (ages 13–18 years) with ADHD and comorbid substance use disorder (SUD) (n = 297, 61% with AUD) receiving a 16-week intervention that combined ADHD pharmacotherapy (OROS-methylphenidate vs. placebo) and drug-focused cognitive-behavioral therapy.

Results

Shifts in drinking risk level during treatment were highly variable in adolescents treated for ADHD/SUD, and influenced by AUD diagnostic status. In the total sample, 15% of participants had a 2-level or greater reduction in WHO drinking risk level, with 59% and 24% showing no change or an increase in risk-level during treatment respectively. Achieving at least a 2-level change in WHO drinking risk level during treatment was associated with greater reduction in ADHD symptoms and better functional outcomes.

Conclusions

These findings parallel the adult AUD literature and provide preliminary support for the use 2-level reductions in WHO risk levels for alcohol use as a clinically valid non-abstinent treatment outcome for youth with ADHD and comorbid AUD.

Systematic Review and Meta-Analysis: Treatment of Substance Use Disorder in Attention Deficit Hyperactivity Disorder

BACKGROUND AND OBJECTIVES

Treating substance use disorder (SUD) in patients with co-occurring attention deficit hyperactivity disorder (ADHD) and SUD may lower medical, psychiatric, and social complications. We conducted a systematic review with meta-analysis to investigate the clinical benefits of pharmacological interventions to treat SUD in patients with ADHD.

METHODS

Articles were searched on Cochrane Central Register of Controlled Trials, PubMed, EBSCO, Google Scholar, Embase, Web of Science, and Ovid MEDLINE from 1971 to 2020. Data for SUD treatment as primary study endpoints and ADHD symptoms management as secondary outcomes were synthesized using random-effects model meta-analysis. Studies (N = 17) were included. The principal measure of effect size was the standardized mean difference (SMD). PROSPERO registration: CRD42020171646.

RESULTS

The pooled effect of pharmacological interventions compared with placebo was small for the reduction in substance use (SMD = 0.405, 95% confidence interval [CI]: [0.252, 0.557], P < .001), abstinence (SMD = 0.328, 95% CI: [0.149, 0.507], P < .001), craving (SMD = 0.274, 95% CI: [0.103, 0.446], P = .002), and the reduction in the frequency of ADHD symptoms (SMD = 0.420, 95% CI: [0.259, 0.582], P < .001). The pooled effect was moderate for the management of withdrawal symptoms (SMD = 0.577, 95% CI: [0.389, 0.764], P = .001]) and the decrease in the severity of ADHD symptoms (SMD = 0.533, 95% CI: [0.393, 0.672], P < .001).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

The magnitude of benefits for pharmacological interventions varies. Despite some limitations, it was positive. This meta-analysis is the first to appraise the benefits of medications to treat SUD in ADHD. It is the groundwork for treatment and risk mitigation. (Am J Addict 2020;00:00-00).

Association between adult ADHD, self-report, and behavioral measures of impulsivity and treatment outcome in cocaine use disorder

A large and growing body of literature supports the association between cocaine addiction and impulsivity. The aim of the study was to test whether pretreatment screening for adult ADHD, and self-report and behavioral measures of impulsivity have prognostic utility in clinical practice with cocaine users. We enrolled a cohort of N = 86 treatment-seeking cocaine users, assisted by a public addiction service, in a 24 week study. At baseline, we performed screening for adult ADHD, assessed the presence of co-occurring mental disorders, and applied measures of drug use severity, trait-like impulsivity (Barratt Impulsiveness Scale; BIS-11), decision-making (Iowa Gambling Task; IGT), risk-taking (Balloon Analogue Risk Task; BART), and ability to inhibit cognitive interference (Stroop Color Word Test; SCWT). Patients positive to the screening for ADHD showed a higher level of self-reported impulsivity and a longer history of drug use, but did not differ from those without ADHD in adherence to psychosocial treatments and number of negative urines for cocaine during the 24 weeks. Among all of the self-report and behavioral measures used, only IGT BIS-11 was associated with cocaine abstention. The small effect size and the problematic direction of the associations found do not give strong support to the routine use of self-regulation measures to guide clinical decisions in public addiction treatment settings.

Temperament correlates in adult ADHD: A systematic review★★

BACKGROUND

Attention deficit and hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children, but adult-ADHD is still an under-diagnosed and untreated condition. Treating adult-ADHD is complex and requires effective strategies for ADHD symptoms and comorbidities. Because of its high comorbidity rate with mood disorders and the growing interest in symptoms of emotional dysregulation in these patients, our aim was to collect studies that investigated temperament correlates in adult people with ADHD, to better understand the association between them and the eventual role of temperament as a prognostic-therapeutic marker.

METHODS

We performed a systematic review of the literature. We included only studies that measured temperament traits in ADHD adults using the Temperament Evaluation of Memphis, Paris and San Diego-Auto-questionnaire (TEMPS-A) or the Temperament and Character Inventory (TCI).

RESULTS

We retrieved 15 papers that used the TCI and 6 papers that used the TEMPS-A. In the TCI studies, ADHD was associated with high scores on Novelty Seeking and Harm Avoidance and low scores on Persistence. For the TEMPS-A studies, ADHD and Bipolar Disorders share some similarities in temperament scores, except for the hyperthymic temperament score.

LIMITATIONS

A comparison between the TCI and TEMPS-A results was not possible. The number of papers included was small. Among them, the type of sample, the number of recruited subjects and the ADHD assessment were very different.

CONCLUSIONS

The majority of ADHD individuals share temperament traits such as lability, irritability and excessiveness of emotional responses. Further research is needed to better understand whether temperament influences the pharmacological response of ADHD patients and whether temperament scores affect the long-term therapeutic outcome.

Risk taking behaviors in relation to Attention Deficit and Hyperactivity Disorder in Iranian male workers: a latent class analysis

BACKGROUND

Risk taking behaviors are a serious risk to the health and safety of workers. The aims of this study were to identify the subgroups of workers on the basis of risk taking behaviors and assess the independent role of ADHD on the membership of participants in each latent class.

METHODS

This cross sectional study was performed on 2434 workers. The sample was selected through random cluster sampling from Kaveh Industrial City. All workers completed five sets of checklists and questionnaires. Data analysis was performed using chi-square, Fisher's exact test, and latent class analysis.

RESULTS

Four latent classes were identified; namely, 1) very low risk (65.6%), 2) low risk (27.8%), moderate risk (4.1%) and, high risk (2.5%). After adjusting for other studied covariates, having ADHD significantly increased the odds of membership in moderate risk class (OR=3.42, 95% CI: 2.21 -5.29) and high risk class (OR=3.10, 95% CI: 1.80 -5.34) compared to very low risk class. Also, having anxiety increased the odds of membership in latent class 2 (OR=1.28, 95% CI: 1.02-1.62), 3(OR=2.15, 95% CI: 1.51-3.10) and 4 (OR=2.06, 95% CI: 1.32-3.22) in comparison to class 1. Among all participants, 187 (7.7%) had ADHD and among studied variables, ADHD has the strongest role in the membership of subjects in different classes.

CONCLUSION

Results from the present study indicate that 6.6% of the workers fell under moderate or high risk class. Focusing on the treatment of ADHD with considering other comorbid factors such as anxiety may be helpful in designing and executing effective programs to reduce risk taking behaviors among workers.

Comparison of the Adult ADHD Self Report Scale Screener for DSM-IV and DSM-5 in a Dually Diagnosed Correctional Population

The diagnosis of Attention Deficit Hyperactivity Disorder in adults with Substance Use Disorders is complicated. A specific screening tool, such as the World Health Organization Adult ADHD Self Report Scale Screener can be the first step in identifying the condition. Recently, the screener has been revised because the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, made some changes to the criteria for Attention Deficit Hyperactivity Disorder. This study compared the screeners based upon the Fourth and Fifth edition of the Manual. One hundred and forty patients, including seventy with Attention Deficit Hyperactivity Disorder, completed both screeners, independent from a clinical diagnostic interview. The sensitivity, specificity, and predictive values were calculated based on four different scoring methods: a categorical score of three or four positive answers, and a dimensional score of twelve or fourteen. Both screening instruments appeared to perform equally without significant differences between them, no matter which scoring system was used. However, the only satisfactory result was obtained using the dimensional scoring with a cutoff of 12, providing a sensitivity and negative predictive value above 80%. This is a lower cut off than recommended in community and clinic samples. It is possible that the cut off of the screener may need to be adjusted depending on the circumstances within which it is used.

Predictors of Dropout From Inpatient Substance Use Treatment: A Prospective Cohort Study

Introduction:

Dropout from inpatient treatment for substance use disorder (SUD) is an ongoing challenge. The aim of this study was to identify demographic, substance use, and psychological factors that predict dropout from postdetoxification inpatient SUD treatment.

Materials and methods:

A total of 454 patients from 5 inpatient SUD centers in Central Norway were consecutively included in this naturalistic, prospective cohort study.

Results:

A total of 132 patients (28%) did not complete the planned treatment stay (dropped out). Cox regression analysis showed that higher levels of intrinsic motivation for changing personal substance use reduced the dropout risk (adjusted hazard ratio [adjHR]: 0.62, 95% confidence interval [CI]: 0.48-0.79). Higher levels of mental distress were associated with an increased risk for dropout (adjHR: 1.48, 95% CI: 1.11-1.97).

Conclusions:

The role of mental health and motivation in reducing dropout risk from inpatient SUD treatment should be targeted in future prospective intervention studies.

Hemispheric brain asymmetry differences in youths with attention-deficit/hyperactivity disorder

Introduction

Attention-deficit hyperactive disorder (ADHD) is the most common neurodevelopmental disorder in children. Diagnosis is currently based on behavioral criteria, but magnetic resonance imaging (MRI) of the brain is increasingly used in ADHD research. To date however, MRI studies have provided mixed results in ADHD patients, particularly with respect to the laterality of findings.

Methods

We studied 849 children and adolescents (ages 6-21 y.o.) diagnosed with ADHD (n = 341) and age-matched typically developing (TD) controls with structural brain MRI. We calculated volumetric measures from 34 cortical and 14 non-cortical brain regions per hemisphere, and detailed shape morphometry of subcortical nuclei. Diffusion tensor imaging (DTI) data were collected for a subset of 104 subjects; from these, we calculated mean diffusivity and fractional anisotropy of white matter tracts. Group comparisons were made for within-hemisphere (right/left) and between hemisphere asymmetry indices (AI) for each measure.

Results

DTI mean diffusivity AI group differences were significant in cingulum, inferior and superior longitudinal fasciculus, and cortico-spinal tracts (p < 0.001) with the effect of stimulant treatment tending to reduce these patterns of asymmetry differences. Gray matter volumes were more asymmetric in medication free ADHD individuals compared to TD in twelve cortical regions and two non-cortical volumes studied (p < 0.05). Morphometric analyses revealed that caudate, hippocampus, thalamus, and amygdala were more asymmetric (p < 0.0001) in ADHD individuals compared to TD, and that asymmetry differences were more significant than lateralized comparisons.

Conclusions

Brain asymmetry measures allow each individual to serve as their own control, diminishing variability between individuals and when pooling data across sites. Asymmetry group differences were more significant than lateralized comparisons between ADHD and TD subjects across morphometric, volumetric, and DTI comparisons.

Interaction between methylphenidate, methadone and different antidepressant drugs on antinociception in mice, and possible clinical implications

OBJECTIVES

Methylphenidate (MPH), a psychostimulant used for treatment of attention deficit hyperactivity disorder (ADHD), is widely used by patients on antidepressants and methadone maintenance treatment (MMT). Preclinical studies showed MPH to exert analgesic effects when given alone or with morphine.

METHODS

Using the hotplate assay on mice, we studied the interaction of acute doses of MPH with sub-threshold doses of methadone and different antidepressant medications and the interaction of increasing doses of MPH with chronic methadone.

RESULTS

Adding a sub-threshold dose of venlafaxine, desipramine or clomipramine to MPH produced significant augmentation of MPH antinociception with each medication (P < 0.05). No such interactions were found between escitalopram and acute methadone. However, addition of increasing doses of MPH to chronic methadone given for 2 weeks using ALZET osmotic mini pumps induced augmentation of the antinociceptive effect of chronic methadone exclusively at high dose of MPH (7.5 mg/kg).

CONCLUSIONS

These findings may implicate the need of an excessive attention to the administration of MPH to MMT patients. The no interaction found between MPH and escitalopram may hint to the possibly safe co-administration of MPH and selective serotonin reuptake inhibitors (SSRIs) to depressed ADHD patients. Further studies are needed in order to validate these possible clinical implications.

Clinical potential of methylphenidate in the treatment of cocaine addiction: a review of the current evidence

Background

Cocaine use continues to be a public health problem, yet there is no proven effective pharmacotherapy for cocaine dependence. A promising approach to treating cocaine dependence may be agonist-replacement therapy, which is already used effectively in the treatment of opioid and tobacco dependence. The replacement approach for cocaine dependence posits that administration of a long-acting stimulant medication should normalize the neurochemical and behavioral perturbations resulting from chronic cocaine use. One potential medication to be substituted for cocaine is methylphenidate (MPH), as this stimulant possesses pharmacobehavioral properties similar to those of cocaine.

Aim

To provide a qualitative review addressing the rationale for the use of MPH as a cocaine substitute and its clinical potential in the treatment of cocaine dependence.

Methods

We searched MEDLINE for clinical studies using MPH in patients with cocaine abuse/dependence and screened the bibliographies of the articles found for pertinent literature.

Results

MPH, like cocaine, increases synaptic dopamine by inhibiting dopamine reuptake. The discriminative properties, reinforcing potential, and subjective effects of MPH and cocaine are almost identical and, importantly, MPH has been found to substitute for cocaine in animals and human volunteers under laboratory conditions. When taken orally in therapeutic doses, its abuse liability, however, appears low, which is especially true for extended-release MPH preparations. Though there are promising data in the literature, mainly from case reports and open-label studies, the results of randomized controlled trials have been disappointing so far and do not corroborate the use of MPH as a substitute for cocaine dependence in patients without attention deficit hyperactivity disorder.

Conclusion

Clinical studies evaluating MPH substitution for cocaine dependence have provided inconsistent findings. However, the negative findings may be explained by specific study characteristics, among them dosing, duration of treatment, or sample size. This needs to be considered when discussing the potential of MPH as replacement therapy for cocaine dependence. Finally, based on the results, we suggest possible directions for future research.

Comorbid attention deficit hyperactivity disorder and substance use disorder complexity and chronicity in treatment-seeking adults

INTRODUCTION AND AIMS

Attention deficit hyperactivity disorder (ADHD) is a known risk factor for substance use disorder (SUD); however, the potential additive contribution of comorbid ADHD to drug-specific dependence in SUD populations is largely unknown. The current study aimed to assess this association between ADHD symptoms and drug-specific SUD complexity and chronicity.

DESIGN AND METHODS

A cross-sectional survey was administered to a convenience sample of 489 adults receiving SUD treatment at 16 Australian drug and alcohol treatment centres between September 2010 and August 2011. Participants were screened for adult ADHD symptoms using the Adult ADHD Self-Report Scale. Associations between ADHD screening status and drug-specific SUD complexity and chronicity were assessed using multivariate logistic and modified Poisson regression analysis, controlling for a range of potential confounders.

RESULTS

Overall, 215 (44%) patients screened positive for concurrent adult ADHD and SUD. After Simes' correction, a significant positive association was observed between ADHD screening status and current amphetamine SUD (odds ratio (OR) = 1.85; 95% confidence interval (CI): 1.19-2.36). Patients who screened positive for ADHD were significantly more likely to report SUD history for heavy alcohol use (OR = 2.05; 95% CI: 1.21-3.45) and amphetamine (OR = 1.96; 95% CI: 1.26-3.06) as well as significantly increased risk of moderate (3-4 years) duration for benzodiazepine and amphetamine SUDs and long (≥5 years) duration for alcohol, opiates other than heroin or methadone, and amphetamine SUDs.

DISCUSSION AND CONCLUSIONS

The findings provide evidence that there is increased drug dependence complexity and chronicity in treatment-seeking SUD patients who screen positively for ADHD, specifically for amphetamine, alcohol, opiates other than heroin or methadone, and benzodiazepines.

Pharmacological treatment of attention deficit hyperactivity disorder with co-morbid drug dependence

BACKGROUND

Drug dependence is frequent in patients with attention deficit hyperactivity disorder (ADHD). Nevertheless, the efficacy and safety of pharmacological treatments in this population are unclear.

METHODS

A systematic review with meta-analysis was performed. Randomised placebo-controlled clinical trials investigating the efficacy of pharmacological treatment in patients with co-occurring ADHD and substance use disorder (SUD) were included. ADHD symptom severity, drug abstinence and all-cause treatment discontinuation were the primary study endpoints. The effects of patient-, intervention- and study-related covariates over the primary outcomes were investigated by means of meta-regression.

RESULTS

Thirteen studies were included, enrolling a total of 1,271 patients. A small to moderate reduction of ADHD symptoms was found. Meta-regression analysis identified the presence of a lead-in period as a covariate associated with reduced efficacy. Conversely, no beneficial effect was observed either on drug abstinence or treatment discontinuation. The efficacy on ADHD symptoms was smaller in studies with a lead-in period. A positive correlation between the efficacy for ADHD and that for SUD was found.

CONCLUSIONS

The efficacy of pharmacological interventions for co-occurring ADHD and SUD has been little investigated. Mixed results were obtained: while pharmacological interventions improved ADHD symptoms, no beneficial effect on drug abstinence or on treatment discontinuation was noted. The strength of the recommendation of pharmacological treatment for co-occurring ADHD and SUD is therefore modest. The study was registered with the international prospective register of systematic reviews (PROSPERO): CRD 4212003414.

Differences in methylphenidate abuse rates among methadone maintenance treatment patients in two clinics

Methylphenidate, an amphetamine-like prescription medication for attention deficit hyperactivity disorder (ADHD) was suspected as being abused among methadone maintenance treatment (MMT) patients. We tested its presence in the routine urine monitoring of all patients in both Tel Aviv and Las Vegas MMT clinics. Data on demographic and addiction history, ADHD (Wender Utah Rating Scale), cognitive impairment (Mini Mental State Exam), and lifetime DSM-IV-TR psychiatric diagnosis from admission were retrieved, and retention following 6 months. None of the 190 patients in Las Vegas tested positive for methylphenidate, while 14.7% (45/306) did in Tel Aviv. Abusers were less educated (p = 0.01), had higher ADHD scores (p = 0.02), lower cognitive scores (p = 0.05), and a higher benzodiazepine (BDZ) abuse rate (p < 0.0005), with no difference in age, gender, duration in MMT, cannabis, opiates, and cocaine abuse and infectious disease. Of the methylphenidate abuse 42.2% have take-home methadone dose privileges. Not like opiate use, being methylphenidate positive did not relate to 6-months retention. Compared to Tel Aviv, Las Vegas patients were more educated, with lower BDZ, and cocaine abuse. The greater abuse of methylphenidate among ADHD subjects might indicate their using it as self-medication, raising a possible indication for its prescription for that subgroup of MMT patients. The high rate of methylphenidate abuse in Israel needs future study.

Stroop task among patients with obsessive-compulsive disorder (OCD) and pathological gambling (PG) in methadone maintenance treatment (MMT)

OBJECTIVES

To evaluate the impaired attention selection (Stroop interference effect) and general performance [reaction times (RTs)] on the Stroop task among methadone maintenance treatment (MMT) patients with obsessive compulsive disorder (OCD), pathological gambling (PG), both PG/OCD or none, and the influence if having ADHD.

METHODS

Eighty-six patients and 15 control subjects underwent the Stroop task, which measured RTs of condition-related words (color, obsessive compulsive disorder, pathological gambling, addiction) and neutral words.

RESULTS

MMT patients had longer RTs on the Stroop task compared with controls. RTs were longer among patients with OCD and in those who abused drugs on the study day. The combined PG/OCD group had the longest RTs, but they were also characterized as abusing more drugs, being older, and having worse cognitive status. Stroop color interference differed only among MMT patients with ADHD, and it was higher among those with OCD than those without OCD. The modified condition-related Stroop did not show any interference effect of OCD, addiction, or gambling words.

CONCLUSIONS

MMT patients had generally poorer performance, as indicated by longer RTs, that were related to clinical OCD, drug abuse, poor cognitive state, and older age. Patients with both clinical OCD and ADHD had a higher Stroop interference effect, which is a reflection of an attention deficit. In order to improve clinical approach and treatment of MMT patients, OCD and ADHD should be evaluated (and treated as needed).

Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature

OBJECTIVE

To raise awareness of attention-deficit/hyperactivity disorder (ADHD) as an underdiagnosed, undertreated, often comorbid, and debilitating condition in adults.

DATA SOURCES

PubMed was searched using combinations of keywords, including ADHD, adult, diagnosis, identify, prevalence, and comorbid, to find articles published between 1976 and 2013.

STUDY SELECTION

In total, 99 articles were selected for inclusion on the basis of their relevance to the objective and importance to and representation of ADHD research, including international guidelines for adults with ADHD.

RESULTS

In a large proportion of children with ADHD, symptoms persist into adulthood. However, although adults with ADHD often experience chaotic lifestyles, with impaired educational and vocational achievement and higher risks of substance abuse and imprisonment, many remain undiagnosed and/or untreated. ADHD is usually accompanied by other psychiatric comorbidities (such as major depressive disorder, anxiety disorder, and alcohol abuse). Indeed, adults with ADHD are more likely to present to a psychiatric clinic for treatment of their comorbid disorders than for ADHD, and their ADHD symptoms are often mistaken for those of their comorbidities. Untreated ADHD in adults with psychiatric comorbidities leads to poor clinical and functional outcomes for the patient even if comorbidities are treated. Effective treatment of adults' ADHD improves symptoms, emotional lability, and patient functioning, often leading to favorable outcomes (eg, safer driving, reduced criminality). A few medications have now been approved for use in adults with ADHD, while a multimodal approach involving psychotherapy has also shown promising results. Conclusions General psychiatrists should familiarize themselves with the symptoms of ADHD in adults in order to diagnose and manage ADHD and comorbidities appropriately in these patients.

Early-age clinical and developmental features associated to Substance Use Disorders in Attention-Deficit/Hyperactivity Disorder in Adults

OBJECTIVE

The main objective was to explore early-age conditions associated to Substance Use Disorders (SUD) in adults with Attention Deficit/Hyperactivity Disorder (ADHD); secondly, to determine which of those conditions are specific to ADHD subjects; and finally, to compare ADHD and non-ADHD subjects in terms of SUD lifetime prevalence and professional, social and personal adjustment.

METHOD

Comparison between ADHD adults with (n=236) and without lifetime SUD (n=309) regarding clinical characteristics of ADHD, externalization disorders, temperamental traits, environmental factors, academic history and family psychiatric history; secondly, ADHD subjects were compared to a non-ADHD group (n=177) concerning those variables.

RESULTS

The following variables were found to be positively associated to SUD in ADHD subjects: ADHD severity, CD and ODD comorbidities, temperamental characteristics ("fearful", "accident prone" and "frequent temper tantrums"), "sexual abuse", "be suspended from school", family history of SUD and ADHD, and male gender; ADHD inattentive subtype and "fearful" were inversely associated to SUD. From those variables, "frequent temper tantrums" was also associated to SUD in non-ADHD subjects. ADHD subjects had higher prevalence of lifetime SUD and greater professional, social and personal impairment than non-ADHD subjects.

CONCLUSION

Findings suggest a significant association between ADHD, SUD and early-age conditions, such as CD and ODD comorbidity; other variables from childhood, namely, ADHD subtype, temper characteristics ("fearful", "accident prone"), "sexual abuse", "be suspended from school" and family history of ADHD are associated to SUD in ADHD subjects, but not in non-ADHD subjects. Moreover, this study confirms both the higher prevalence of lifetime SUD and greater professional, social and personal impairment in ADHD subjects than in non-ADHD subjects.

Trends in the utilisation of psychotropic medications in Australia from 2000 to 2011

OBJECTIVE

This study examined longitudinal trends in the dispensing of psychotropic medications in Australia from January 2000 to December 2011.

METHOD

Dispensing data for the major classes of psychotropic medications (antidepressants, anxiolytics, sedatives, antipsychotics, mood stabilisers and attention-deficit hyperactivity disorder (ADHD) medications) were obtained from the Drug Utilisation Sub-Committee of the Australian Department of Health and Ageing. Results were expressed in terms of defined daily doses/1000 population/day (DDDs/1000/day).

RESULTS

There was a 58.2% increase in the dispensing of psychotropic drugs in Australia from 2000 to 2011, driven by major increases in antidepressants (95.3% increase in DDDs/1000/day), atypical antipsychotics (217.7% increase) and ADHD medications (72.9% increase). Dispensing of anxiolytics remained largely unchanged, while sedatives and typical antipsychotics decreased by 26.4% and 61.2%, respectively. Lithium dispensing remained static while valproate and lamotrigine increased markedly. In 2011, antidepressants accounted for 66.9% of total psychotropic DDDs/1000/day totals, far greater than anxiolytics (11.4%), antipsychotics (7.3%), mood stabilisers (5.8%), sedatives (5.5%), or ADHD medications (3.0%). Sertraline, olanzapine, valproate and methylphenidate were the most frequently dispensed antidepressant, antipsychotic, mood stabiliser and ADHD medication, respectively, while diazepam and temazepam were the most commonly dispensed anxiolytic and sedative.

CONCLUSIONS

Psychotropic utilisation markedly increased in Australia between 2000 and 2011. Some potential concerns include: (1) the continuing high use of benzodiazepines, particularly alprazolam, despite their problematic effects; (2) the rapid increase in serotonin noradrenaline reuptake inhibitor (SNRI) use, given their more complex side-effect profile relative to selective serotonin reuptake inhibitors (SSRIs); and (3) the dramatic increase in antidepressant prescriptions despite questions about the efficacy of these drugs in mild to moderate depression. Finally, some limitations are identified regarding use of the DDDs/1000/day metric, which can distort estimates of utilisation of specific drugs when the defined daily dose is higher or lower than the formulation most commonly dispensed by pharmacies.

Substance use disorders in children and adolescents with attention-deficit/hyperactivity disorder: implications for treatment and the role of the primary care physician

OBJECTIVES

Review the association between attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) in children and adolescents. Discuss treatment implications and the role of the primary care physician in the management of this comorbidity.

DATA SOURCES

Articles published from 1991 to 2007 were identified through a MEDLINE search using the search terms attention-deficit/hyperactivity disorder and substance use disorder.

STUDY SELECTION

Publications cited include reviews of substance use disorders in children and adolescents with ADHD, manuals of diagnostic tests, and 69 studies of substance use disorders in children and adolescents with ADHD. No non-English-language publications were identified.

DATA SYNTHESIS

Recent reports identify SUD in a high proportion of respondents with ADHD and ADHD in a high proportion of respondents with many types of SUD. Factors that appear to increase the risk for SUD include comorbid psychiatric disorders, particularly conduct disorder. Pharmacotherapy for ADHD appears not to increase the risk for subsequent SUD. Guidelines for the evaluation and treatment of patients with comorbid ADHD and SUD are outlined. Psycho-stimulants carry the risk for misuse by both patients and family members through diversion. Although nonstimulants such as atomoxetine have low abuse potential, they appear to be less efficacious than stimulants. Formulations that have the potential to lower the abuse liability of stimulants are being developed. These include a transdermal form of methylphenidate that has been shown to be efficacious in the treatment of ADHD and a prodrug stimulant, lisdexamfetamine, recently approved for the treatment of ADHD. Clinical data indicate that lisdexamfetamine is efficacious, and significantly lower likability scores were seen with lisdexamfetamine than with equivalent oral doses of d-amphetamine sulfate.

CONCLUSIONS

Pharmacotherapy may reduce the risk for SUD in patients with ADHD. Psycho-stimulants remain the first-line therapy for the core symptoms of ADHD. New formulations of pharmacologic agents with a reduced potential for abuse are being developed.

Drug and alcohol use in college students with and without ADHD

OBJECTIVE

This study examines differences in reported levels of drug and alcohol use between college students with and without ADHD.

METHOD

The Michigan Alcohol Screening Test (MAST) and several self-report and interview questions, developed by Barkley, were used to examine the drug and alcohol use of college students with and without ADHD.

RESULTS

Between-group differences were found on the MAST and in the endorsement of marijuana use. Subtype differences were also found on the MAST. Several factors, including medication treatment status, ethnicity, class standing, and gender were found to be differentially related to problematic drinking behaviors.

CONCLUSIONS

Difficulties in self-regulation may put college students with ADHD at a higher risk of problematic drinking and the subsequent risk for alcohol-use disorders than their peers. Possible explanations for results are discussed in terms of theory, prevention efforts, and future research.

Attention deficit hyperactivity disorder and obsessive-compulsive disorder among former heroin addicts currently in methadone maintenance treatment

BACKGROUND

The aim of this study was to evaluate the prevalence of childhood and adulthood attention deficit hyperactivity disorder (ADHD) and clinical obsessive-compulsive disorder (OCD) among adult patients in methadone maintenance treatment (MMT) and to characterize possible risk factors.

SAMPLING AND METHODS

A random sample of 154 current MMT patients was studied for childhood ADHD (Wender Utah Rating Scale), current clinical OCD (Yale-Brown Obsessive Compulsive Scale), lifetime trauma history and modified Addiction Severity Index for demographics, as well as any lifetime DSM-IV-TR psychiatric diagnosis.

RESULTS

Fifty-one patients (33.1%) had childhood ADHD, and more of this group currently had clinical OCD compared to patients who did not have childhood ADHD (55.3 vs. 30.1%). The two groups did not differ with regard to gender and age of admission to MMT. Logistic regression found that the childhood ADHD group had a higher risk of having OCD [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.6-8.8], more severe nicotine smoking (OR 1.4, 95% CI 1.1-1.7) and fewer years of education (OR 0.8, 95% CI 0.6-1) and were more likely to have a DSM-IV-TR axis II disorder (OR 4.3, 95% CI 1.4-13.4) and a history of falls (OR 4.3, 95% CI 1.4-12.9).

CONCLUSIONS

Although ADHD is more prevalent among males in the general population, the rates in our MMT population were similar in each gender. One third of our sample had suffered from ADHD during childhood, which may have led them to self-medicate with drugs and thus to addiction. Childhood ADHD was associated with current OCD, and both conditions were highly prevalent among our MMT patients. The reason for a history of repeated falls warrants further study.

Psychostimulant treatment of combat-related posttraumatic stress disorder

The objective of this paper is to describe three cases of combat-related posttraumatic stress disorder (PTSD), largely refractory to standard medication treatment who responded well to psychostimulant treatment. Symptoms of PTSD potentially result from chronic, stress-induced dopaminergic dysfunction in the prefrontal cortex/basal ganglia system. Psychostimulants, by their relative propensity to enhance dopamine (DA) activity within these brain regions, may have particular value in targeting this dysfunction. Evidence of dopaminergic dysfunction following chronic stress is reviewed and possible mechanism of action of psychostimulants is explored. Psychostimulants appeared to be well tolerated and beneficial in the treatment of the cases of combat-related PTSD reported. General applicability of the use of psychostimulants in combat- and non-combat-related PTSD awaits further study. The potential implications of these findings in further delineating pathophysiology and treatment in PTSD deserve further exploration.

The influence of sex-linked genetic mechanisms on attention and impulsivity

It is now generally agreed that there are inherent sex differences in healthy individuals across a number of neurobiological domains (including brain structure, neurochemistry, and cognition). Moreover, there is a burgeoning body of evidence highlighting sex differences within neuropsychiatric populations (in terms of the rates of incidence, clinical features/progression, neurobiology and pathology). Here, we consider the extent to which attention and impulsivity are sexually dimorphic in healthy populations and the extent to which sex might modulate the expression of disorders characterised by abnormalities in attention and/or impulsivity such as attention deficit hyperactivity disorder (ADHD), autism and addiction. We then discuss general genetic mechanisms that might underlie sex differences in attention and impulsivity before focussing on specific positional and functional candidate sex-linked genes that are likely to influence these cognitive processes. Identifying novel sex-modulated molecular targets should ultimately enable us to develop more effective therapies in disorders associated with attentional/impulsive dysfunction.

Long-term outcomes with medications for attention-deficit hyperactivity disorder: current status of knowledge

Attention-deficit hyperactivity disorder (ADHD), a common neurobehavioural disorder characterized by inattention, hyperactivity and impulsivity, is a chronic disorder and often persists into adulthood. CNS stimulants have been the most well known treatment for ADHD for several decades due to their high effectiveness, good safety profiles and relatively minor adverse effects. Non-stimulant agents, including atomoxetine, extended-release guanfacine and extended-release clonidine (US FDA approved), and several non-FDA-approved agents, such as bupropion and tricyclic antidepressants (TCAs), were recently proven to be effective alternatives to the stimulants in several open-label and placebo-controlled trials. However, most medication trials for ADHD have been short term and thus have not provided information on the long-term outcomes of ADHD treatment. Since the medical treatment of many children with ADHD, especially those with more severe symptoms or co-morbid disorders, has to be continued for several years, recent studies have shifted their focus from the acute effectiveness of stimulants or non-stimulant drugs to the long-term outcomes of medications for ADHD. Evidence has shown that stimulants, along with the non-stimulants atomoxetine and extended-release guanfacine, are continuously effective for 24-month treatment periods with few and tolerable adverse effects.

Childhood and adolescent attention-deficit hyperactivity disorder: diagnosis, clinical practice guidelines, and social implications

PURPOSE

To review the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD), present an overview of the effects that ADHD has on family dynamics, school performance, and substance abuse, and provide an overview of the American Academy of Pediatrics (AAP) clinical practice and treatment guidelines.

DATA SOURCES

An extensive health science literature review was carried out using PubMed and Cumulative Index to Nursing and Allied Health Literature. Other information was collected by searching reference lists of published reports.

CONCLUSIONS

The diagnostic criteria and guidelines are important to make an accurate clinical assessment and manage a child with ADHD. Early diagnosis and treatment of ADHD decreases academic failure, family conflict, social isolation, substance abuse, and occupational adversity in later years for these children.

IMPLICATIONS FOR PRACTICE

Often primary care nurse practitioners are the first healthcare provider a child with ADHD will see. Awareness of the diagnostic criteria and treatment for children with ADHD can assist with early identification and perhaps eliminate much impairment that accompanies this chronic disorder.

ADHD medication use, adherence, persistence and cost among Texas Medicaid children

OBJECTIVES

(1) Describe ADHD medication use, adherence and persistence. (2) Determine factors (e.g., medication type, demographics, concomitant medication use) associated with ADHD medication adherence and persistence. (3) Compare ADHD medication costs.

METHODS

Continuously enrolled Texas Medicaid children (3-18 years) with ≥ 2 ADHD prescription claims (July 2002-December 2008) were included. Prescription claims were grouped by medication type (i.e., immediate-release, extended-release, prodrug, non-stimulant); medication class (i.e., stimulant, non-stimulant); and duration of action (i.e., long-acting, short-acting). Adherence, using medication possession ratio, was measured continuously and dichotomously (80% cut-off). Persistence was days of continuous therapy without a 30-day gap and medication costs were reimbursement amount paid to dispensing pharmacies.

RESULTS

The study sample (n = 62,789) was primarily 6-12 years (61.7%) and male (69.2%). The majority of the subjects were prescribed extended-release agents (70.3%), stimulant agents (86.4%), and long-acting agents (84.5%). Adherence and persistence (adherence mean ± SD; adherence dichotomous; persistence mean ± SD) varied among medication type and was highest for non-stimulants (52.5 ± 30.9; 25.8%; 153.3 ± 124.3), followed by extended-release stimulants (52.1 ± 30.2; 24.1%; 143.7 ± 120.8), prodrug stimulants (47.6 ± 30.9; 21.1%; 113.3 ± 100.5) and immediate-release stimulants (37.2 ± 27.1; 9.8%; 95.4 ± 92.6). Logistic regression showed immediate-release stimulant users were 67% less adherent than non-stimulant users (p < 0.0001) and linear regression showed immediate-release, extended-release and long-acting users (p < 0.0001) were significantly less persistent than non-stimulant users. Females, increase in total number of medications, and comorbid medications were associated with better adherence and persistence. Non-stimulant agents ($4.04 ± $2.15) had the highest mean medication cost per patient per day and immediate-release stimulants had the lowest ($1.24 ± $0.97).

CONCLUSIONS

ADHD medication adherence and persistence was suboptimal. Although there was no difference in adherence between long-acting stimulant and non-stimulant users, non-stimulant users were more persistent compared to stimulant users. This study was limited due to the use of retrospective prescription claims data, which cannot capture actual patient use patterns, ICD-9 diagnoses, family history and support, or side effect profiles. Because ADHD can be effectively treated with pharmacotherapy, providers should be proactive in identifying patients with poor adherence and intervene to address barriers to medication adherence and persistence.

Reinforcing effects of methamphetamine in an animal model of attention-deficit/hyperactivity disorder--the spontaneously hypertensive rat

Substrains of the Spontaneously Hypertensive rat (SHR), a putative animal model of Attention-Deficit/Hyperactivity Disorder (ADHD), have demonstrated increased sensitivity to many drugs of abuse, including psychostimulants. Therefore, it was suggested that studies in SHR may help elucidate ADHD and comorbidity with substance use disorder (SUD). However, the drug intake profile of the SHR in the most relevant animal model of drug addiction, the self-administration (SA) test, and its response on the conditioned place preference (CPP) paradigm are not yet determined. In the present study, we employed SA and CPP tests to investigate the reinforcing effects of the psychostimulant methamphetamine in an SHR substrain obtained from Charles River, Japan (SHR/NCrlCrlj). Concurrent tests were also performed in Wistar rats, the strain representing "normal" heterogeneous population. To address if the presence of ADHD behaviors further increases sensitivity to the rewarding effect of methamphetamine during adolescence, a critical period for the onset of drug abuse, CPP tests were especially conducted in adolescent Wistar and SHR/NCrlCrlj. We found that the SHR/NCrlCrlj also acquired methamphetamine SA and CPP, indicating reinforcing effects of methamphetamine in this ADHD animal model. However, we did not observe increased responsiveness of the SHR/NCrlCrlj to methamphetamine in both SA and CPP assays. This indicates that the reinforcing effects of methamphetamine may be similar in strains and that the SHR/NCrlCrlj may not adequately model ADHD and increased sensitivity to methamphetamine.

A placebo-controlled trial of atomoxetine in marijuana-dependent individuals with attention deficit hyperactivity disorder

This study evaluated the effects of atomoxetine on the symptoms of attention deficit hyperactivity disorder (ADHD) and marijuana use in marijuana-dependent adults. In conjunction with motivational interviewing, participants received either atomoxetine (n = 19) or matching placebo (n = 19) for 12 weeks. Participants randomized to atomoxetine had greater improvement in ADHD on the Clinical Global Impression-Improvement scale than participants treated with placebo. No treatment group differences in self-rated ADHD symptoms, overall Wender-Reimherr Adult Attention Deficit Disorder Scale scores, or marijuana use outcomes were noted. These results suggest that atomoxetine may improve some ADHD symptoms but does not reduce marijuana use in this population. 

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.

METHODS

The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.

RESULTS

Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?

CONCLUSIONS

ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

Intermittent methylphenidate during adolescent development produces locomotor hyperactivity and an enhanced response to cocaine compared to continuous treatment in rats

The consequences of chronic methylphenidate (MPH) administration in adolescents for the treatment of attention-deficit/hyperactivity disorder (ADHD) remain to be fully understood. Studies in rats indicate that the pharmacokinetics of psychostimulant administration can powerfully influence the behavioral and neural consequences of chronic treatment. The purpose of the present study was to assess the effects of intermittent (0.8 or 1.6mg/kg, s.c., twice daily) versus continuous (1.6 or 3.2mg/kg/day via osmotic minipump) MP administration across four weeks of adolescent development in rats. Results indicate that intermittent treatment produced hyperactivity in a novel open field and increased sensitivity to both the reinforcing and locomotor-activating effects of cocaine. In contrast, continuous MPH resulted in a hypoactive response to the novel open field and a reduced sensitivity to both operant and non-contingent cocaine. To the extent that the continuous release condition models the sustained-release formulations utilized in human ADHD treatment, we interpret these data to indicate that sustained-release formulations are less likely to advance a risk of subsequent substance abuse.

Screening and imputed prevalence of ADHD in adult patients with comorbid substance use disorder at a residential treatment facility

BACKGROUND

Although attention deficit/hyperactive disorder (ADHD) is a common comorbidity in individuals who are diagnosed with substance use disorder (SUD), little data currently exist on the utility of screening tools in large samples of adults with SUD in inpatient treatment and the prevalence of ADHD in this population. The aims of this study were to assess the screen positive rate on the Adult ADHD Self Report Scale (ASRS) v.1.1 Screener in a large sample of adults being treated for SUD in a residential treatment facility (RTF) and to establish the imputed prevalence of adult ADHD.

METHODS

Adults with SUD who were either newly admitted (abstinent for < 1 week) or in treatment in the RTF (abstinent < 3 months) were administered the ASRS v.1.1 Screener. Adults who screened positive on the ASRS v1.1 Screener (>or= 4/6 significant items) were then administered the Adult Clinician Diagnostic Scale (ACDS) v.1.2 to establish a diagnosis of ADHD and the positive predictive value (PPV) in this population. The imputed prevalence of adult ADHD was calculated based on the known rate of ADHD in the screened positive cohort and a calculated rate of ADHD in the screened negative sample based on prior studies of the ASRS v1.1 Screener in community-based and managed care samples.

RESULTS

1064 adults were screened via the ASRS v.1.1 Screener, with 92 screening positive (8.6% had >or= 4 significant items present). Fifty-three of those who screened positive were diagnosed as having adult ADHD (PPV = 57.6%). The imputed prevalence of adult ADHD in this population was 7.5%.

CONCLUSIONS

The PPV for the ASRS v1.1 Screener for adult ADHD in this sample of adults with SUD was similar to that observed in a prior study of a managed care sample, but was somewhat less than that observed in the community-based sample. The imputed prevalence rate for comorbid ADHD in this study of adults with SUD in a RTF was similar to, but slightly lower than the prevalence rate of ADHD in patients with any SUD observed in the community-based sample.

Widespread cortical thinning is a robust anatomical marker for attention-deficit/hyperactivity disorder

OBJECTIVE

This cross-sectional study sought to confirm the presence and regional profile of previously reported changes in laminar cortical thickness in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) compared with typically developing control subjects.

METHOD

High-resolution magnetic resonance images were obtained from 22 (19 male and 3 female subjects; mean age 11.7 years) children and adolescents with ADHD and 22 age- and sex-matched control subjects (mean age 11.7 years). Brain tissue volumes were estimated for each subject. Cortical pattern matching methods were used to sample measures of laminar thickness at high spatial frequency across homologous regions of the cortex. Volume and thickness measures were compared across diagnostic groups with and without controlling for general intelligence. False discovery rate correction confirmed regional results.

RESULTS

The subjects with ADHD exhibited significant reductions in overall brain volume, gray matter volume, and mean cortical thickness compared with the controls, whereas white matter volumes were significantly increased in ADHD. Highly significant cortical thinning (false discovery rate-corrected p < .0006) was observed over large areas of the frontal, temporal, parietal, and occipital association cortices and aspects of motor cortex but not within the primary sensory regions.

CONCLUSIONS

Cortical thickness reductions present a robust neuroanatomical marker for child and adolescent ADHD. Observations of widespread cortical thinning expand on earlier cross-sectional findings and provide further evidence to support that the neurobiological underpinnings of ADHD extend beyond prefrontal and subcortical circuits.

The neuropharmacology of ADHD drugs in vivo: insights on efficacy and safety

Results from in vivo techniques, especially intracerebral microdialysis in freely-moving rats, have provided insights into potential mechanisms responsible for the efficacy and safety of catecholaminergic drugs for ADHD treatment. The drugs reviewed come from distinct pharmacological classes: psychostimulant releasing agents, eg d-amphetamine; psychostimulant reuptake inhibitors, eg dl-threo-methylphenidate (dl-MPH), and non-stimulant reuptake inhibitors, eg atomoxetine. Psychostimulants, which currently deliver the best efficacy in treating ADHD, exhibit the following characteristics on extraneuronal catecholamine concentrations in rodent brain in vivo: 1) They enhance the efflux and function of both noradrenaline and dopamine in the central nervous system. 2) The increase of dopamine efflux that they produce is not limited to cortical regions. 3) They have a rapid onset of action with no ceiling on drug effect. d-Amphetamine has a mechanism independent of neuronal firing rate, displacing intraneuronal stores of catecholamines, delaying their reuptake and inhibiting catabolism by monoamine oxidase. dl-MPH has an enigmatic, extraneuronal action that is neuronal firing rate-dependent and reuptake transporter-mediated, yet paradoxically, almost as powerful as that of d-amphetamine. In safety terms, these powerful catecholaminergic effects also make the psychostimulants liable for abuse. Since efficacy and safety derive from the same pharmacological mechanisms, it has not yet been possible to separate these two components. However, the development of once-daily psychostimulant formulations and a prodrug, lisdexamfetamine, has improved patient compliance and markedly reduced scope for their diversion/abuse. This review will discuss the in vivo pharmacological profiles of approved catecholaminergic drugs for treatment of ADHD and implications for their clinical efficacy and abuse liability.

Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications

OBJECTIVE

We sought to better understand the trend for prescription attention-deficit/hyperactivity disorder (ADHD) medication abuse by teenagers.

METHODS

We queried the American Association of Poison Control Center's National Poison Data System for the years of 1998-2005 for all cases involving people aged 13 to 19 years, for which the reason was intentional abuse or intentional misuse and the substance was a prescription medication used for ADHD treatment. For trend comparison, we sought data on the total number of exposures. In addition, we used teen and preteen ADHD medication sales data from IMS Health's National Disease and Therapeutic Index database to compare poison center call trends with likely availability.

RESULTS

Calls related to teenaged victims of prescription ADHD medication abuse rose 76%, which is faster than calls for victims of substance abuse generally and teen substance abuse. The annual rate of total and teen exposures was unchanged. Over the 8 years, estimated prescriptions for teenagers and preteenagers increased 133% for amphetamine products, 52% for methylphenidate products, and 80% for both together. Reports of exposure to methylphenidate fell from 78% to 30%, whereas methylphenidate as a percentage of ADHD prescriptions decreased from 66% to 56%. Substance-related abuse calls per million adolescent prescriptions rose 140%.

CONCLUSIONS

The sharp increase, out of proportion to other poison center calls, suggests a rising problem with teen ADHD stimulant medication abuse. Case severity increased over time. Sales data of ADHD medications suggest that the use and call-volume increase reflects availability, but the increase disproportionately involves amphetamines.

Atomoxetine treatment of adults with ADHD and comorbid alcohol use disorders

OBJECTIVE

Adults with attention-deficit/hyperactivity disorder (ADHD) have higher rates of alcohol and drug use disorders than adults without ADHD. The study aim was to determine if atomoxetine was superior to placebo in improving ADHD and alcohol use in recently abstinent adults with ADHD and comorbid alcohol use disorder.

METHODS

Adults with DSM-IV diagnoses of ADHD and alcohol abuse and/or dependence were abstinent from alcohol at least 4 days (maximum 30 days) before study randomization. Participants received atomoxetine (25-100mg daily) or placebo for 12 weeks. ADHD symptoms were assessed using ADHD Investigator Symptom Rating Scale (AISRS) total score. Time-to-relapse to heavy alcohol use was analyzed using a 2-sided log-rank test based on Kaplan-Meier estimates and cumulative heavy drinking events over time were evaluated post hoc with recurrent-event analysis.

RESULTS

Subjects received atomoxetine (n=72) or placebo (n=75) and 80 subjects completed the 12-week double-blind period (n=32 and 48, respectively). ADHD symptoms were significantly improved in the atomoxetine cohort compared to placebo (AISRS total score mean [S.D.], atomoxetine: -13.63 [11.35], P<.001; placebo: -8.31 [11.44], P<.001, difference: P=.007; effect size=0.48). No significant differences between treatment groups occurred in time-to-relapse of heavy drinking (P=.93). However, cumulative heavy drinking days were reduced 26% in atomoxetine-treated subjects versus placebo (event ratio=0.74, P=.023). There were no serious adverse events or specific drug-drug reactions related to current alcohol use.

CONCLUSIONS

This 3-month, double-blind, placebo-controlled study of atomoxetine in adults with ADHD and comorbid alcohol use disorder demonstrates clinically significant ADHD improvement, and inconsistent effects on drinking behavior.

New treatments for cocaine dependence: a focused review

Cocaine, already a significant drug problem in North and South America, has become a more prominent part of the European drug scene. Cocaine dependence has major somatic, psychological, psychiatric, socio-economic, and legal implications. No specific effective pharmacological treatment exists for cocaine dependence. Recent advances in neurobiology have identified various neuronal mechanisms implicated in cocaine addiction and suggested several promising pharmacological approaches. Data were obtained from Medline, EMBASE, and PsycINFO searches of English-language articles published between 1985 and June 2007 using the key words: cocaine, addiction, cocaine dependence, clinical trials, pharmacotherapy(ies) singly and in combination. Large well-controlled studies with appropriate statistical methods were preferred. Pharmacological agents such as GABA agents (topiramate, tiagabine, baclofen and vigabatrin) and agonist replacement agents (modafinil, disulfiram, methylphenidate) seem to be the most promising in treatment of cocaine dependence. The results from trials of first- and second-generation neuroleptics are largely negative. Aripiprazole, a partial dopaminergic agonist that may modulate the serotonergic system, shows some promise. Preliminary results of human studies with anti-cocaine vaccine, N-acetylcysteine, and ondansetron, are promising, as are several compounds in preclinical development. While no medication has received regulatory approval for the treatment of cocaine dependence, several medications marketed for other indications have shown efficacy in clinical trials. An anti-cocaine vaccine and several compounds in preclinical development have also shown promise. Findings from early clinical trials must be confirmed in larger, less selective patient populations.

A qualitative review of issues arising in the use of psycho-stimulant medications in patients with ADHD and co-morbid substance use disorders

OBJECTIVE

This review addresses the relationship between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs), with an emphasis on factors that determine the potential for psychostimulant abuse. Strategies for identification and treatment of patients with ADHD who are at risk for, or have, co-morbid SUD are also addressed.

RESEARCH DESIGN AND METHODS

The article was based on a qualitative review of current literature addressing co-morbid ADHD and SUD.

DISCUSSION

Adolescent and adult patients with ADHD are at increased risk for SUD, as well as a number of other psychiatric disorders. Psychostimulant agents like methylphenidate (MPH) and mixed amphetamine salts (MAS) are effective first-line pharmacotherapies for ADHD; however, they are Schedule II controlled substances with a potential for abuse. Evidence suggests that treatment of ADHD during childhood with stimulant agents may reduce the risk of developing SUD later on. Factors associated with the highest risk of SUD in patients with ADHD include co-morbid antisocial personality disorder, bipolar disorder, an eating disorder, severe ADHD and/or antisocial behavior symptoms, and dropping out of school. Treatment initiation during adolescence or young adulthood also has been linked to increased risk of polydrug use and non-medical stimulant use, a pattern of behavior consistent with a risk of SUD development. Treatment plans for patients with ADHD and co-morbid SUD should include behavioral interventions, careful monitoring, and when appropriate, pharmacotherapy. When oral formulations of psychostimulants are used at recommended doses and frequencies, they are unlikely to yield effects consistent with abuse potential in patients with ADHD. Long-acting stimulant formulations and non-stimulants, like atomoxetine or bupropion, have a lower potential for abuse, and provide several safe and effective treatment options for the development of a comprehensive management plan for patients with co-morbid ADHD and SUD.

CONCLUSIONS

The present review is neither exhaustive nor systematic. Moreover, the reviewed studies vary widely with regards to methodology and patient populations. In light of these limitations, several conclusions are still warranted. Patients with ADHD are at increased risk for SUD. Under certain conditions, psychostimulants may be a pharmacologic option in the treatment of patients with co-morbid ADHD and SUD. However, clinicians should be mindful of the risks and benefits of this treatment approach in a high-risk population and should also bear in mind the labeling guidelines when working with this co-morbidity.

Brain activation, response inhibition, and increased risk for substance use disorder

BACKGROUND

Youth at high risk for developing substance use disorders (SUDs) often exhibit differences which suggest inhibitory impairments when compared to average risk youth.

METHODS

To examine the underlying neural activity related to these impairments, functional MRI (fMRI) was employed in adolescents during an antisaccade task requiring inhibition of an eye movement response. Each subject's level of neurobehavioral disinhibition (ND) was assessed using a multi-informant, multi-method approach, which has been shown to be highly predictive of SUD onset. The fMRI data was categorized into neural regions of interest according to total frontal, parietal, occipital, and temporal lobe activation.

RESULTS

Results demonstrated that ND score was negatively correlated with total amount of frontal activation, but was not significantly correlated with total activation in any other neural region.

CONCLUSIONS

These results indicate deficits in frontal activation in youth with high amounts of ND, suggesting a possible developmental delay of executive processes in high-risk youth.

Polymorphisms TaqI A of the DRD2, BalI of the DRD3, exon III repeat of the DRD4, and 3' UTR VNTR of the DAT: association with childhood ADHD in male African-Caribbean cocaine dependents?

The conflicting results reported by genetic studies with the variants of the genes coding for the dopaminergic system in cocaine addicts could be partially explained by the difficulties to constitute homogenous sample of patients. Childhood attention-deficit/hyperactivity disorder (ADHD), and/or impulsivity are frequently associated with cocaine addiction and could participate in the heterogeneity of the samples in cocaine addicts. Accordingly, it is hypothesized that cocaine addiction would be associated with the variants of the genes coding for the dopamine system in an homogenized sample of cocaine addicts, especially in individuals with childhood ADHD comorbidity, or with a high impulsivity score. The potential association of the variants TaqI A of the DRD2, BalI of the DRD3, exon III repeat of the DRD4, and 3' UTR VNTR of the DAT was examined in African-Caribbean males, smoked-cocaine dependents. All the subjects were assessed with the Diagnostic Interview of Genetic Studies, the Barratt's impulsivity scale, and the Wender Utah rating scale for childhood ADHD. A positive association was found with the DRD2 and DRD4 polymorphisms in the subgroups of patients with childhood ADHD, or with a high impulsivity score, which represented, respectively, 53.3 and 73.0% of the patients. Conversely, no positive association was found for any of the polymorphisms studied when the group of patients was examined as a whole. Therefore, our results suggest that the clinical dimensions of childhood ADHD and of impulsivity could be taken into account to homogenize the samples of patients in cocaine association studies.

Patterns and predictors of medication compliance, diversion, and misuse in adult prescribed methylphenidate users

OBJECTIVES

To examine patterns and predictors of medication compliance, diversion, and misuse in a sample of adults with prescriptions for the stimulant medication methylphenidate (MPH).

METHODS

Sixty-six adults currently prescribed MPH (53% male) completed structured interviews and provided details regarding their medication and other substance use histories.

RESULTS

On average, participants reported using their medication as prescribed on 14.5 (SD 11.7) of the past 30 days; 44% admitted to diverting it and 29% admitted to inappropriate use. While analyses revealed that medication misuse, diversion, and level of compliance were interrelated and all associated with concurrent illicit substance use, each also had other distinct associations. Specifically, MPH misuse was associated with the use of illicit stimulants such as amphetamine and cocaine, diversion with age and age of MPH prescription, and compliance with participation in an attention deficit hyperactivity disorder (ADHD) support group. Regression analyses revealed that misuse and poor compliance were both best predicted by concurrent illicit substance use, while the model that best predicted diversion included age of first MPH prescription (younger) and MPH misuse.

CONCLUSIONS

Poor medication compliance, diversion, and misuse are relatively common and interrelated among adult MPH users. MPH prescriptions should be monitored closely in individuals with histories of illicit substance use.

Efficacy of central nervous system stimulant treatment for cocaine dependence: a systematic review and meta-analysis of randomized controlled clinical trials

AIMS

To evaluate the efficacy of central nervous system (CNS) stimulants compared with placebo for the treatment of cocaine dependence.

METHODS

A systematic review and meta-analysis was carried out. Bibliographic databases were searched, reference lists of retrieved studies were hand-searched and the first authors of each study were contacted. All randomized controlled clinical trials (RCCT) comparing the efficacy of any CNS stimulant with placebo in cocaine-dependent patients were included. Quantitative data synthesis was performed for each single CNS stimulant and for all CNS stimulants.

RESULTS

Nine RCCT met the inclusion criteria. These RCCT included 640 patients and compared five CNS stimulants: mazindol, dextroamphetamine, methylphenidate, modafinil and bupropion with placebo. No CNS stimulant improved study retention [RR = 0.94 (0.81-1.09)] or cocaine use [RR = 0.90 (0.79-1.02)]. An exploratory analysis using indirect estimations of cocaine use showed that the proportion of cocaine-positive urine screens was lower with dexamphetamine than with placebo [RR = 0.73 (0.60-0.90)] and that all CNS stimulants pooled together also suggested a significant decrease of cocaine use [RR = 0.87 (0.77-0.99)]. Data on craving could not be meta-analysed due to heterogeneity, but no RCCT found differences in cocaine craving between active drug and placebo except one, whose outcome favoured dexamphetamine. No serious adverse event (AE) was reported. Average of AE-induced dropouts was low and was greater for CNS stimulants than placebo: 4.4% versus 1.3% (P = 0.03).

CONCLUSION

The main outcomes of this study do not support the use of CNS stimulants for cocaine dependence. Nevertheless, secondary analyses provide some hopeful results that encourage further research with these drugs, mainly with dexamphetamine and modafinil.

The consequences of attention-deficit/hyperactivity disorder in adults

Until recently, attention-deficit/hyperactivity disorder (ADHD) was a diagnosis reserved for children and adolescents as it was believed to dissipate before adulthood. New evidence, however, supports the persistence of ADHD beyond adolescence, and it is now recognized as a chronic neurobehavioral disorder in adults. Adults with ADHD have difficulties with school, work, family interactions, and social activities. Although treatments are available for adult ADHD, many patients never receive an accurate diagnosis that would afford them appropriate therapeutic intervention. If left untreated, adult ADHD can cause significant personal, social, and economic burdens that can have a negative impact on overall quality of life. This article discusses how ADHD presents in adults and the effects of the disorder on educational, occupational, interpersonal, and social functioning. Currently available treatments for ADHD in adults are also reviewed.

The complexity of ADHD: diagnosis and treatment of the adult patient with comorbidities

Attention-deficit/hyperactivity disorder (ADHD) is an impairing but usually treatable condition. Popular culture propagates the myth that ADHD recedes with age; this is not the case. Although it is common, <20% of adults with ADHD are diagnosed or treated. Adults with ADHD show significant comorbidities with depressive disorders, anxiety disorders, substance use, oppositional defiant disorder, personality disorders, sleep problems, and learning disabilities. However, symptoms that result from ADHD, such as mood symptoms or lability, are often mistaken for comorbid disorders. Comorbidity with ADHD impacts treatment compliance, treatment response, and patient insight. Insufficient data on the interaction between ADHD and comorbidities impedes proper diagnosis and treatment. Better clinical tools for assessing these conditions are needed. Food and Drug Administration-approved pharmacologic treatments for adult ADHD include stimulants, dexmethylphenidate, and the nonstimulant atomoxetine. Effect sizes of approved medicines at approved doses are half those seen in children. Adults may also need longer duration of medication effects than children. Short-acting stimulants are likely to result in poorer adherence and have a higher risk for diversion or abuse. Risk of abuse is a major concern; stimulant treatments are controlled substances, and children with ADHD show increased risk of substance abuse. Psychosocial interventions may be beneficial in treating both ADHD and comorbidities.In this expert roundtable supplement, Margaret Weiss, MD, PhD, presents a comprehensive overview of complications surrounding differential diagnosis in adults with ADHD. Next, Mark A. Stein, PhD, reviews evaluation, comorbidity, and development of a treatment plan in this population. Finally, Jeffrey H. Newcorn, MD, provides a discussion on the pharmacologic options available for adults with ADHD, considering dosages specific to adults and common comorbidities.

ADHD in Children, Adolescents, and Adults

Attention-deficit-hyperactivity disorder (ADHD) is a commonly occurring, heritable neurobehavioral disorder distributed worldwide that does not typically resolve after childhood. The significant impact of ADHD on an individual's family, relationships, educational performance, and performance at work is now well established. Medical treatment of ADHD is effective, not only alleviating symptoms but also improving overall functioning. It is imperative that primary care physicians be well versed in this disorder and its clinical features across the age groups. The primary care physician should be able to screen, diagnose, educate, and initiate medication management in patients with uncomplicated ADHD.